The reason for bleeding in the majority of cases is misdirection of the spray towards the septum, active management in the first instance is stop the spray for a few days and use aseptic or a local lubricating spray. Either lubrication should be applied with the 'non-touch' technique as patients often use their finger or a cotton bud to install the ointment which defeats the purpose.

Prevention is best especially if the intranasal steroids are necessary so I advise the use of the X-Factor approach which is directing the spray laterally towards the medial cants of the eye on the same side thus optimising delivery of the medication to the turbinates and avoiding the septal mucosa as much as possible. This advice which is liked by children was based on a clinical nugget that I received from an experienced German ORL college some year ago which was to present the spray to the right nostril with the left hand and vice versa. This method by crossing fingers for the nose while instructing her led to one of my adolescent patients first suggesting the X-Factor

Thanks Dr.John. I have two questions. What about azelastine, if the azelastine spray caused the bleeding, what should be the management? The same as the steroids? And with regards to the antiseptic technique, using saline intranasal drops is sufficient?

Thank you Mostafa - the same applies for Azelastine as for steroid sprays.

I have what I call the Granny elbow rule for the ear and the nose which is nothing smaller than your elbow should be inserted into either orifice.

The other Granny rule for ENT is don't speak with your mouth full!

If there is epistaxis any form of intrusion including saline drops could exacerbate it

let the healing happen naturally but if the allergy symptoms are troublesome at the same time consider oral antihistamines and/or Montelukast.

The best antiseptic is to leave the nose alone

Why don't you recommend saline drops? Won't it prevent the crusting that is following the drying of the blood that formed inside?

Screenshot from

PG Textbook of Pediatrics: Volume 2: Infections and Systemic Disorders

What's your take on this?

I consider it incorrect - nasal moisturiser and bedroom humidification the proper way to deal with the problem - if there is bleeding there is.a wound, if there is a wound would you put salt on it?

Yeah John, like the way you deal with burns. You wash the burned part of the body with water and soap then rinse with saline daily.

no - not like that - you should just leave the nose alone - my final words

What could happen or what side effects could occur if you apply saline? Mentioning the references you depend upon

This is scientific discussion, so you should be able to mention references or evidence

A melhor conduta seria a utilização de soluções de soro fisiológicos ou salinas contínuas para umidificar e lavar as narinas evitando o uso repetitivo de esteróides, evitando desta forma o sangramento. Somente em casos agudos ou severos.

The nasal mucus blanket composed of sol layer and gel layer. The percentage of each should be maintained for the best mucociliary clearance which is one of the major defense mechanisms of nasal mucosa against infection. Therefore, dry nose will be liable to infection and any wound will not heal. I agree with Dr. Mustafa Elsersy... this is ABC in management together with stopping nasal steroids and and avoidance of dry circumstances.

Hello Mustafa, I gues that you suspect an adverse drug reaction which is quite common for these agents (more than 1/10 patients for Fluticasonpropionate and 1/10 to 1/100 patients for Azelastin, source: drug labels in Germany, adverse drug reactions). One possibility that can be used alone or as an add-on are systematic antihistaminergic agents (preferably the second or "third" generation such as Cetirizine, Loratadine or Desloratadine). However, the risk for systematic adverse drug reactions is of course higher in this case. It depends on the effectiveness of the local therapy with Azelastin and Fluticasone if you should restart them. A pro argument is that they are usually very effective and (apparently not in this case) are well tolerated. If the patient reports a suficcient effectiveness in the weeks before epistaxis, I would recommend to restart the therapy. However I would start with one drug and not both at once to assess which is the one that caused the epistaxis. You also have the option to switch to Mometasonefuroat instead of Fluticasonepropionate (lower frequency of epistaxis, "only" 1/10 to 1/100 patients) or Levocabastine (same frequency reported as in Azelastine). I would also recommend to advise the patient to use the right hand to apply it to the left nostril and vice versa, especially with the glucocorticoide spray. Hereby the patient does not apply it directly to the septum which can cause a mucosal atrophy and thereby bleeding. Hope this helps, best of luck to you!